Forms For South Dakota
Insured through:
Wellmark Blue Cross Blue Shield of South Dakota
Blue Cross Blue Shield GlobalTM Core Claim Form:
Reporting Health Care Fraud & Abuse
Appeal FormPDF File
See also How to Appeal
File an External Review - South Dakota Division of InsuranceExternal Site
Authorization for Disclosure to Housing AuthorityPDF File
This form is used to authorize Wellmark to disclosure premium information to a housing authority at the request of the individual.
Authorization to Use or Disclose Protected Health InformationPDF File
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.
Personal Representative Appointment and Authorization to Release Protected Health InformationPDF File
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them.
